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Based on record review, observations and interviews, the psychiatric hospital failed to ensure patients received care in a safe setting as evidenced by failing to secure areas of egress while escorting a patient between secure areas.
Findings:

Review of the hospital's policy TX.003 titled, "Elopement Procedure" revealed in part:
Policy - It is the policy of this hospital to prevent patient elopements whenever possible and to provide consistent methods of follow-up in the event that they do occur.
Procedure - Patients most frequently at high risk for elopement are adolescents, chemical dependency patients and patients under involuntary admission status. 8. Patients are managed safely during transport (i.e., gym/mealtimes/outdoors, off-unit areas, therapy offices, off grounds appointments/ER visitation by: Staff position at front and rear of group during transport to keep the group together, not permitting patients to run ahead or lag behind. In the event of an elopement-7. The hospital Safety Officer will conduct an environmental assessment to evaluate any contributing environmental factors.

Observation on 11/02/2023 at 9:13 a.m. revealed S3LPN and S4MHT escorting/transporting Patient 2 to the gym. The walkway gate was currently unlocked and open and the driveway gates leading to the street and parking lot were both open. S3LPN was holding Patient 2's hand as they crossed the driveway toward the locked gym entrance. S4MHT accompanied S3LPN as they unlocked the chained padlock to the gate leading into the interior courtyard of the gym and escorted Patient 2 into the courtyard and locked the gate behind them.

Interview on 11/02/2023 at 9:24 a.m., S3LPN acknowledged they were supposed to close and lock the driveway gates prior to exiting the walkway and escorting/transporting the patient to the gym.

Interview on 11/02/2023 at 9:30 a.m., S4MHT acknowledged they were supposed to close and lock the driveway gates prior to exiting the walkway and escorting/transporting the patient to the gym.